Elsevier

Journal of Affective Disorders

Volume 227, February 2018, Pages 613-617
Journal of Affective Disorders

Review article
Mobile technology for medication adherence in people with mood disorders: A systematic review

https://doi.org/10.1016/j.jad.2017.11.022Get rights and content

Highlights

  • Technology-based approaches to promote medication adherence are increasing in need.

  • Results showed satisfaction and feasibility of mobile technology.

  • Results showed reduction in mood symptoms.

  • Mobile technology can be utilized for symptom tracking.

Abstract

Background

Medication non-adherence is a critical challenge for many patients diagnosed with mood disorders (Goodwin and Jamison, 1990). There is a need for alternative strategies that improve adherence among patients with mood disorders that are cost-effective, able to reach large patient populations, easy to implement, and that allow for communication with patients outside of in-person visits. Technology-based approaches to promote medication adherence are increasingly being explored to address this need. The aim of this paper is to provide a systematic review of the use of mobile technologies to improve medication adherence in patients with mood disorders.

Methods

A total of nine articles were identified as describing mobile technology targeting medication adherence in mood disorder populations.

Results

Results showed overall satisfaction and feasibility of mobile technology, and reduction in mood symptoms; however, few examined effectiveness of mobile technology improving medication adherence through randomized control trials.

Limitations

Given the limited number of studies, further research is needed to determine long term effectiveness.

Conclusions

Mobile technologies has the potential to improve medication adherence and can be further utilized for symptom tracking, side effects tracking, direct links to prescription refills, and provide patients with greater ownership over their treatment progress.

Introduction

Mood disorders, including depression and bipolar disorder, are common and chronic disorders that impose a significant public health burden (Mathers, 2008). There are a number of psychopharmacological treatments for these disorders but they are not universally effective and can sometimes be associated with uncomfortable side effects that impact treatment adherence. Medication non-adherence is a critical challenge for many patients diagnosed with mood disorders (Goodwin and Jamison, 1990). In bipolar disorder, non-adherence to long-term prophylactic pharmacotherapy has been reported in anywhere from 20% to 60% of patients, with a median of 41% not adhering to proper medication regimens. One study found that 40% of patients with bipolar disorder do not take mood stabilizer medication consistently (Colom et al., 2000), while another larger study reported that 51% of patients were noncompliant in some manner with their psychopharmacology treatment (Keck et al., 1997). In addition, it was found that among patients diagnosed with bipolar disorder or schizoaffective disorder who were recently admitted to the hospital, 64% were noncompliant with their medication regimen prior to the hospitalization (Keck et al., 1997). In major depressive disorder, non-adherence with antidepressant medications ranges from 10% to 60% (Lingam and Scott, 2002). Despite the fact that proper medication adherence is a major factor in the prevention of severe mood episode recurrence, hospitalizations, and suicidality (Gonzalez‐Pinto et al., 2006), it has been a challenge to maintain across patient demographics and therapeutic modalities (Cuijpers et al., 2008).

There is substantial research on the patient and medication factors that may lead to medication non-adherence. Most notably, there is a strong correlation with comorbid Axis II diagnoses and substance abuse disorders (Keck et al., 1997). Goodwin and Jamison (1990) described some risk factors for medication non-adherence in patients with bipolar disorder, including being in the first year of treatment, having a history of non-adherence, younger age, male gender, fewer reported episodes (manias and depressions), and overall reports of “missing” the euphoria of the manic and/or hypomanic episodes. Aside from patient factors, there are also medication characteristics that are associated with poor adherence. Side effects such as fatigue, weight gain, dry mouth, and low libido are typically referenced by patients as reasons for discontinuing medication against medical advice (Uher et al., 2009). In addition, difficulties with remembering to refill prescriptions on time is a reported problem for some mood disorder patients (Goodwin and Jamison, 1990). Patient and medication factors such as those above, coupled with a typical lag time of 6–8 weeks for the therapeutic effect of a newly prescribed medication to become apparent to the patient contribute to consistently high rates of treatment non-adherence in patients with mood disorders (Rush et al., 2004).

Clinicians have sought to address the problem of non-adherence using different strategies, such as cognitive-behavioral approaches, psycho-education for patients and their families, and strengthening of social support, especially during the time of medication trials (Aikens et al., 2015). Skills training and cognitive-behavioral approaches typically target memory and/or attention issues by providing visual schedules, pharmacy-based reminders, and daily pill boxes (Kreyenbuhl et al., 2016). However, these approaches appear to be insufficient for the majority of patients as demonstrated by the persistently high percentage of medication non-adherence among patients with mood disorders. With other chronic diseases, such as Tuberculosis, Hepatitis C, and HIV, direct observational therapy (DOT) has been used successfully to improve medication adherence (Rajasekaran and Khandelwal, 2013). DOT is a highly recommended approach in which a health care provider watches the patient swallow the prescribed medication to ensure adherence (Rajasekaran and Khandelwal, 2013). Among people with serious mental illnesses, DOT has been utilized to improve adherence of clozapine in HIV-infected patients with schizophrenia; however, it has not been examined in patients with mood disorders (Nejad et al., 2009).

There is a need for alternative strategies that improve adherence among patients with mood disorders that are cost-effective, able to reach large patient populations, easy to implement, and that allow for communication with patients outside of in-person visits. Technology-based approaches to promote medication adherence are increasingly being explored to address this need. These include strategies such as at-home computerized face-to-face conversations with an animated relational agent and electronic pill dispensers which record date and time when a patient opens a pill bottle (Kreyenbuhl et al., 2016) and medication bottles with an electronic chip embedded in the container (i.e., MEMS cap, Med-eMonitor, eCaps, and Medsignals) to measure the time of opening and closing or changes in weight of the bottle (Sajatovic et al., 2010). Other strategies have used pills with added biological tracers that are detectable in biological samples (i.e., blood or urine) to more accurately document and improve adherence (Sajatovic et al., 2010, Shine and McDonald, 1999). These technology-based approaches are intriguing, but their wider use in busy clinical practices remains limited.

Ubiquitous and easy to use mobile technologies, such as smartphone/tablet applications are especially promising for tackling medication non-adherence in patients with mental illnesses. Mobile technologies have been utilized and shown to be effective in increasing medication adherence in patients with schizophrenia (Granholm et al., 2012, Moore et al., 2015). There is a great deal of interest in using mobile technology as well for patients with mood disorders, but it remains unclear if they can be part of an effective strategy to improve clinical outcomes in these patients. The aim of this paper is to provide a systematic review of the use of mobile technologies (tablets and/or smartphones) in interventions to improve medication adherence in patients with mood disorders.

Section snippets

Methods

A search of English language biomedical journal articles from January 2011 to January 2017 in the PsychINFO and PUBMED databases was performed. All articles containing the terms (“depressive” or “mood” or “bipolar”) and (“medication adherence” or “compliance” or “medication treatment” or “treatment adherence”) and (“mhealth” or “mobile app” or “mobile health” or “SMS text messaging”) in the title or abstract were identified (n = 92). The abstracts of these articles were then inspected by two

Study design and characteristics

A total of nine articles were identified as relevant primary papers. Study design and demographic characteristics of these studies are summarized in Table 1. Eight of these primary papers were observational studies and one was a randomized control trial (RCT).

Study sample sizes ranged from 8 to 1256 participants, with a median study sample size of 58 participants. Three studies explicitly included participants with a DSM diagnosis of major depressive disorder. An additional three studies

Conclusion

We report here one of the first systematic reviews of studies using mobile technologies targeting medication adherence in patients with mood disorders. Overall, these studies reported that using mobile technologies can improve medication adherence in mood disorders. The majority were pilot studies, but demonstrated the feasibility and acceptability of mobile for patients with mood disorders. In addition, they provided preliminary evidence that interventions with mobile technologies can be

Acknowledgments

None.

Role of funding source

Authors above did not provide any financial support for the conduct of the research and/or preparation of the article.

Kelly Rootes-Murdy is the current research assistant at the Johns Hopkins Mood Disorders Center in Baltimore, MD. She received her Master’s degree in Clinical Psychology from Loyola University in Baltimore, MD in 2017.

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  • Cited by (0)

    Kelly Rootes-Murdy is the current research assistant at the Johns Hopkins Mood Disorders Center in Baltimore, MD. She received her Master’s degree in Clinical Psychology from Loyola University in Baltimore, MD in 2017.

    Kara L. Glazer is the current research coordinator at the Johns Hopkins Mood Disorders Center in Baltimore, MD. She received her Bachelor’s degree in Psychology from Dickinson College in Carlisle, PA in 2013.

    Michael J. Van Wert is a clinical social worker at Johns Hopkins Bayview Medical Center who works in the Intensive Outpatient Program for Adults (IOPA). His research interests include the prevention and treatment of trauma, stabilization of acute behavioral health symptoms, and integration of measurement-based care into practice.

    Francis Mondimore, M.D. is the director of the Mood Disorders Clinic at the Johns Hopkins Bayview Medical Center, where he leads a team of clinicians specializing in the care of persons with mood disorders. Here, in conjunction with the National Network of Depression Centers, the clinical and research team is investigating the longitudinal course of serious depression and bipolar disorder in order to determine what constitute “best practices” for the care of individuals with these illnesses. Dr. Mondimore is an Associate Professor in the Department of Psychiatry and Behavioral Sciences at the Johns Hopkins School of Medicine where he is also engaged in research projects on pharmacologic strategies for the management of mood disorders and pharmacogenetic studies of treatment responses to psychotropic medications.

    Peter P. Zandi, Ph.D., is a psychiatric epidemiologist with expertise in studying the pharmacoepidemiology and genetic epidemiology of complex psychiatric disorders. He is a Professor with joint faculty appointments in the Department of Mental Health at the Johns Hopkins Bloomberg School of Public Health and the Department of Psychiatry and Behavioral Sciences in the School of Medicine. He is also Research Co-Director of the Mood Disorders Center in the Department of Psychiatry, and Director of the NIMH supported Psychiatric Epidemiology Training (PET) Program. Dr. Zandi is engaged in a range of translational research projects on mood disorders, including on the genetic causes of these disorders, pharmacologic strategies for their treatment and prevention, and pharmacogenetic studies of treatment responses to psychotropic medications. He is also interested in developing new approaches that leverage informatics technologies to carry out pharmacoepidemiology and genetic epidemiology research on psychiatric disorders more efficiently.

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